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January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 1 Geriatric Assessment Practical Approaches for Primary Care Practitioners Presented by Dr. Marwan.

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Presentation on theme: "January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 1 Geriatric Assessment Practical Approaches for Primary Care Practitioners Presented by Dr. Marwan."— Presentation transcript:

1 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 1 Geriatric Assessment Practical Approaches for Primary Care Practitioners Presented by Dr. Marwan Zoghbi Moderator : Dr. Nabil Naja Dar Al-Ajaza Al-Islamia Hospital Beirut, Jan 2003

2 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 2 Challenges of Geriatrics in Primary Care Short visit times Short visit times Low reimbursement rates Low reimbursement rates Multiple co-morbidities Multiple co-morbidities Needs of caregiver and patient Needs of caregiver and patient Ever-expanding diagnostic and therapeutic options Ever-expanding diagnostic and therapeutic options Cross cultural communication Cross cultural communication

3 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 3 KEYS TO SURVIVAL Time management Time management You dont have to do everything yourself You dont have to do everything yourself Working knowledge of geriatric assessment tools Working knowledge of geriatric assessment tools Determine when to refer someone for comprehensive geriatric assessment Determine when to refer someone for comprehensive geriatric assessment

4 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 4 Overview and Learning Objectives At the end of this lecture, you should be able to answer: At the end of this lecture, you should be able to answer: Why is assessment important? Why is assessment important? What are some useful tools for Assessment? What are some useful tools for Assessment? How can assessment be incorporated into a short visit? How can assessment be incorporated into a short visit? What are some strategies for making a visit more efficient? What are some strategies for making a visit more efficient? Is there any Evidence to support the use of Geriatric Assessment? Is there any Evidence to support the use of Geriatric Assessment?

5 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 5 Why is assessment important? Lebanese are aging !: Lebanese are aging !: 1972: ~ 4% 1972: ~ 4% 1996: ~ 7.5% 1996: ~ 7.5% 2000: 8.6% 2000: 8.6% 2025: ~ 14% 2025: ~ 14% 2050: ~ 20% 2050: ~ 20% Life expectancy: Life expectancy: 1950: 54 years 1950: 54 years 2002: ~ 70 years 2002: ~ 70 years

6 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 6 Why is Assessment Important? Americans are aging! Americans are aging! 1998: Age 65+ numbered 34 million 1998: Age 65+ numbered 34 million 2030: Age 65+ will number 70 million 2030: Age 65+ will number 70 million Largest increases in those over age 85 Largest increases in those over age 85 Older population more ethnically diverse Older population more ethnically diverse Majority of elderly will be cared for by internists and family practitioners Majority of elderly will be cared for by internists and family practitioners ACP 1998: Internists should be measuring functional deficits and identifying dependency needs of older adults ACP 1998: Internists should be measuring functional deficits and identifying dependency needs of older adults

7 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 7 Usual care may not meet elders needs Usual care may not meet elders needs The 80+ survey: The 80+ survey: 75% said MD unaware of social needs 75% said MD unaware of social needs 37% said MD unaware of physical needs 37% said MD unaware of physical needs 42% said MD was unaware of their emotional needs 42% said MD was unaware of their emotional needs 50% said Medical Care could be improved 50% said Medical Care could be improved Patterson 1998 Why is Assessment Important?

8 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 8 What is Geriatric Assessment? Different models and definitions exist Different models and definitions exist Geriatrics is often best practiced as an interdisciplinary team approach Geriatrics is often best practiced as an interdisciplinary team approach Evaluates different domains: medical, cognitive, psychological, social, physical Evaluates different domains: medical, cognitive, psychological, social, physical Expands scope of interest to include caregiver and environment Expands scope of interest to include caregiver and environment Emphasis on optimization of function and increase in active life expectancy Emphasis on optimization of function and increase in active life expectancy

9 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 9 Active Life Expectancy at 75 Total ActiveDisabled White women Black women Black men White men Guralnik, NEJM, 1993

10 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 10 DOMAINS OF CGA FUNCTIONAL STATUS QUALITY OF LIFE MEDICAL COGNITIVE AFFECTIVE ENVIRONMENTAL ECONOMIC SOCIAL SUPPORT

11 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 11 Selected Tools for Assessment Lachs: Simple screen Lachs: Simple screen Similar version validated by Moore and Siu in 1996 Similar version validated by Moore and Siu in 1996 Good inter-rater reliability Good inter-rater reliability Easy to use Easy to use 7-10 minutes to administer 7-10 minutes to administer Can be administered by non-MD personnel Can be administered by non-MD personnel UCSF version UCSF version

12 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 12 Areas covered in Lachs Tool Vision Vision Hearing Hearing Incontinence Incontinence Falls and Gait Falls and Gait Upper extremity function Upper extremity function Cognition ( 3 item recall) Cognition ( 3 item recall) Depression Depression Medications Medications ADLs and IADLs ADLs and IADLs

13 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 13 Underreporting Common Underreporting of symptoms common in the elderly Many elderly attribute treatable symptoms to aging and stated nothing can be done about it anyway 1/2-1/3 of symptoms may go unreported to physicians So its important to do a geriatric ROS

14 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 14 Quick Clues to Dementia About 2/3 of mild-moderate dementia missed by providers About 2/3 of mild-moderate dementia missed by providers Content empty speech Content empty speech Loss of IADL function Loss of IADL function Inability to recall 3 items at 5 minutes Inability to recall 3 items at 5 minutes Inability to draw clock Inability to draw clock Larson 1998, JAGS Siu 1991, Ann Int Med

15 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 15 Screening Tests for Dementia Test & ResultLRPTP given prevalence of: 3 item recall2%10%50% recalls < recalls Clock Draw abnormal almost normal normal Siu, Ann Intern Med, 1991

16 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 16 The MMSE Well validated Well validated Good predictive accuracy Good predictive accuracy Easy and relatively quick to administer Easy and relatively quick to administer Cut off usually cited as 24 Cut off usually cited as 24 Sensitivity 85% Sensitivity 85% Specificity 90% Specificity 90% Tombaugh JAGS 1992, Siu, Annals 1991 Tombaugh JAGS 1992, Siu, Annals 1991

17 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 17 The MMSE: Limitations Education, cultural, and age biases Education, cultural, and age biases Crum JAMA 1994 Crum JAMA 1994 Score impacted by vision, literacy, depression. Score impacted by vision, literacy, depression. Floor and ceiling effects Floor and ceiling effects Best to use as one tool in evaluation Best to use as one tool in evaluation

18 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 18 Falls and gait disorders are common among the elderly & are a major cause of morbidity and mortality 1/3 of elderly fall each year Major cause of NH placement Falls, mobility impairment, and functional impairment closely related Falls and Gait Disorders

19 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 19 Falls and Gait Disorders Fall History Assessment: Fall History Assessment: Ask the Patient: Have you fallen in the past year? Ask the Patient: Have you fallen in the past year? Gait Assessment Gait Assessment Up and Go Test Up and Go Test Rise from chair, walk 10 feet, turn around, walk back, sit down Rise from chair, walk 10 feet, turn around, walk back, sit down Timed Up and Go Test – normal less than 10 seconds Timed Up and Go Test – normal less than 10 seconds Tinetti ( or POMA) Tinetti ( or POMA) Timed Up and Go: If greater than 30 seconds, only 23% independent in tub or shower, only 4% can climb stairs

20 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 20 BALANCE AND GAIT EVALUATION Balance Balance Sitting, rising from a chair Sitting, rising from a chair Immediate and prolonged standing balance Immediate and prolonged standing balance Withstanding nudge on chest Withstanding nudge on chest Standing balance with eyes closed Standing balance with eyes closed TURNING BALANCE (360 degrees) TURNING BALANCE (360 degrees) Sitting down Sitting down Gait observations Initiation of gait Step length, height, continuity, symmetry Walking stance Amount of trunk sway Path deviation Tinetti. Am J Med 1986; 80:429

21 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 21 Why Assess Function? Medical conditions may present first (or only) as functional disturbances Medical conditions may present first (or only) as functional disturbances Functional loss highly impacts quality of life Functional loss highly impacts quality of life Functional losses may lead to further disability and institutionalization Functional losses may lead to further disability and institutionalization Functional losses impact patient and caregiver Functional losses impact patient and caregiver

22 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 22 Functional Impairments ADLs Bathing Dressing Toileting Transfers Continence Feeding IADLs Using telephone Shopping Food preparation Housekeeping Laundry Transportation Medications Managing money

23 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 23 Difficulty with ADLs and IADLs by Age US Census Bureau, 1990

24 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 24 AADLs Patient specific activities that can be used to detect subtle functional losses in high functioning patients Patient specific activities that can be used to detect subtle functional losses in high functioning patients Can be job or recreation oriented Can be job or recreation oriented Socializing, playing bridge, working, playing golf, playing music, dancing, practicing law, flying a plane, gardening. Socializing, playing bridge, working, playing golf, playing music, dancing, practicing law, flying a plane, gardening.

25 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 25 Other measures available Upper extremity mobility Upper extremity mobility Manual dexterity Manual dexterity Lower extremity mobility Lower extremity mobility Combination of both Combination of both Balance and gait evaluation Balance and gait evaluation

26 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 26 Using Functional Information Use functional status as baseline Use functional status as baseline Use it to guide recommendations for exercises, PT, adaptive devices for impairments Use it to guide recommendations for exercises, PT, adaptive devices for impairments Consider home evaluation for highly impaired Consider home evaluation for highly impaired Potential marker of caregiver stress Potential marker of caregiver stress Useful for evaluating risk of & need for placement Useful for evaluating risk of & need for placement

27 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 27 Depression Geriatric depression scale Geriatric depression scale 30 item instrument 30 item instrument Yes/no to series of questions Yes/no to series of questions minutes, self or interviewer to administer minutes, self or interviewer to administer Scores Scores <9 less probability <9 less probability >11 higher likelihood >11 higher likelihood >18 highest possibility >18 highest possibility Brink. Clin Gerontol 1982; 1:37

28 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 28 Geriatric depression scale Shorter version Shorter version 15 item, less certain diagnostic accuracy 15 item, less certain diagnostic accuracy SCORE: 0-5 NORMAL, SCORE: 0-5 NORMAL, >5 SUGGEST DEPRESSION >10 almost always depression Sheikh, Yesavage. Clin Gerontol. 1986; 5:

29 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 29 Disadvantage in frail elderly Hard to administer with concomitant cognitive impairment Hard to administer with concomitant cognitive impairment Cornell scale Cornell scale 19 items caregiver is asked variety of questions 19 items caregiver is asked variety of questions Scores: 8-12 possible depression, >12 probable Scores: 8-12 possible depression, >12 probable Useful screening for major depression in both demented and non-demented patients Useful screening for major depression in both demented and non-demented patients

30 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 30 Other psychiatric problems to look for Delirium (confusion assessment method) Delirium (confusion assessment method) Anxiety Anxiety Hostility Hostility Psychosis Psychosis Behavioral problems Behavioral problems

31 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 31 Malnutrition risk factors Chronic disease Chronic disease Poverty Poverty Social isolation Social isolation Cognitive impairment Cognitive impairment Functional disability Functional disability

32 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 32 Indicators of poor nutrition Impaired wound healing Impaired wound healing Increased surgical complications Increased surgical complications Increased mortality Increased mortality

33 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 33 Screening assessment WEIGHT <100 lbs IN AMBULATORY OLDER PATIENTS, NOT ALWAYS ACCURATE WEIGHT <100 lbs IN AMBULATORY OLDER PATIENTS, NOT ALWAYS ACCURATE Weight loss > 10% body weight Weight loss > 10% body weight Physical findings Physical findings Chelosis, glossitis, loss of subQ body fat, muscle, wasting, edema Chelosis, glossitis, loss of subQ body fat, muscle, wasting, edema Lab Lab Decreased serum albumin, lymphocytes<1000 Decreased serum albumin, lymphocytes<1000 Body mass index, mid arm circumference, triceps skin folds Body mass index, mid arm circumference, triceps skin folds

34 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 34 Visual and hearing impairments Visual impairment Visual impairment 13% older persons 13% older persons Hearing impairment Hearing impairment Age 65-74: 25% Age 65-74: 25% Age >85: 50% Age >85: 50% Increase risk injury Increase risk injury Increased disability in physical and psychosocial function Increased disability in physical and psychosocial function Decreased quality of life Decreased quality of life

35 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 35 Vision screening Sensitivity and specificity for screening tests by primary care Dr not established Sensitivity and specificity for screening tests by primary care Dr not established Limited accuracy of glaucoma screening Limited accuracy of glaucoma screening Snellen test Snellen test Specific questions regarding vision Specific questions regarding vision

36 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 36 Hearing screening Hand held audioscope $500 Hand held audioscope $500 40db TONES AT 500, 1000, 2000, 4000 hz 40db TONES AT 500, 1000, 2000, 4000 hz Takes 90 seconds, 94% sensitive, 72% specific Takes 90 seconds, 94% sensitive, 72% specific Increase accuracy with short questionnaire Increase accuracy with short questionnaire Whispered voice or finger rub Whispered voice or finger rub Cheaper Cheaper Subject to variation between examiners Subject to variation between examiners

37 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 37 Remember the caregiver! 80% of care of elderly is informal & unpaid High caregiver stress highly correlated with increased risk of institutionalization, excess caregiver mortality, abuse, and neglect Education & support of caregiver may be critical part of keeping your patient at home and safe Zarit Caregiver Burden Interview or question about caregiver stress (caregiver alone) Solutions: Respite, day care, support groups

38 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 38 Abuse and Neglect: Helpful Questions S - Do you feel Safe at home? What Stress do you feel in your relationship? S - Do you feel Safe at home? What Stress do you feel in your relationship? A - Do you feel Afraid or have you been Abused by any of your caregivers? A - Do you feel Afraid or have you been Abused by any of your caregivers? F - Are there any Family or Friends that you could ask for help or support? F - Are there any Family or Friends that you could ask for help or support? E – Do you have a safe place to go in case of an Emergency? Is it an Emergency now? E – Do you have a safe place to go in case of an Emergency? Is it an Emergency now?

39 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 39 Abuse and Neglect: Caregiver Risk Factors and Clues Caregiver does not come to appointments Caregiver does not come to appointments Is concerned about medical costs Is concerned about medical costs History of substance abuse, mental health problems, conflicts with patient History of substance abuse, mental health problems, conflicts with patient Dominates interview, wont leave, wont let patient talk Dominates interview, wont leave, wont let patient talk Defensive, hostile, or indifferent Defensive, hostile, or indifferent Dependence on patient for income/housing Dependence on patient for income/housing

40 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 40 Review medications Elderly use 3X more medications than younger patients Elderly use 3X more medications than younger patients Drug distribution, elimination, excretion, & pharmacodynamics altered in elderly Drug distribution, elimination, excretion, & pharmacodynamics altered in elderly ADRs and drug-drug interactions increase markedly with # drugs used ADRs and drug-drug interactions increase markedly with # drugs used Medications linked to reversible dementias, falls, incontinence, hospitalizations, death Medications linked to reversible dementias, falls, incontinence, hospitalizations, death

41 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 41 Nonadherance and # Drugs Percent Adherence # of drugs

42 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 42 Reviewing Medications Have patient bring in all medications, including OTCs, herbs, dietary supplements Have patient bring in all medications, including OTCs, herbs, dietary supplements Ask about other providers Ask about other providers Consider home visit if high risk Consider home visit if high risk Eliminate questionable medications Eliminate questionable medications Simplify regimens or consider Medi-sets, visiting nurses, or involving caregiver Simplify regimens or consider Medi-sets, visiting nurses, or involving caregiver For new medications, start low and go slow, but get there! For new medications, start low and go slow, but get there!

43 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 43 Practical Tips for Practicing Geriatrics in your Office

44 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 44 Planning the initial office interview Relaxed and efficient atmosphere Relaxed and efficient atmosphere Good acoustic conditions and no interruptions Good acoustic conditions and no interruptions Efficient appointment system Efficient appointment system Wheel chair accessible Wheel chair accessible Hearing device: amplifier and microphone Hearing device: amplifier and microphone Paper/plastic bag test (bring all meds) Paper/plastic bag test (bring all meds) Obtain prior medical records Obtain prior medical records

45 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 45 Make Your Life Easier Send out pre-visit questionnaire (e.g., UCLA) Send out pre-visit questionnaire (e.g., UCLA) Use brief screening tests (e.g. Lachs) or single questions when possible Use brief screening tests (e.g. Lachs) or single questions when possible Use more detailed tests only when indicated Use more detailed tests only when indicated Have forms handy Have forms handy Train nursing and ancillary staff to perform screening tests Train nursing and ancillary staff to perform screening tests

46 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 46 Interview techniques In clinic: obtain data at several appointments over time In clinic: obtain data at several appointments over time Introduce yourself Introduce yourself Ask how the patient would like to be addressed Ask how the patient would like to be addressed Traditional chief complaint may not be appropriate for most older patients Traditional chief complaint may not be appropriate for most older patients How can I help you today? Better than what seems to be the problem? How can I help you today? Better than what seems to be the problem?

47 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 47 Make Your Life Easier Discuss patient goals early Discuss patient goals early Focus visit on patients goals and priorities, not you clinics quality improvement checklist Focus visit on patients goals and priorities, not you clinics quality improvement checklist Realize that patients goals and priorities may change over time Realize that patients goals and priorities may change over time Change your clinics quality improvement checklist to reflect the priorities of geriatrics! Change your clinics quality improvement checklist to reflect the priorities of geriatrics!

48 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 48 History of the elderly patient Patient profile, social history Patient profile, social history History of current problems History of current problems Review of symptoms and systems Review of symptoms and systems Medical history Medical history Medication history Medication history Caregivers status Caregivers status Family history Family history Functional history, ADLss Functional history, ADLss Community services currently provided Community services currently provided

49 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 49 Minimal social assessment Content of average day for patient Content of average day for patient Abilities in ADLs Abilities in ADLs Suitability and safety of home Suitability and safety of home Availability, attitude and health of caregivers and neighbors Availability, attitude and health of caregivers and neighbors Services received and/or needed Services received and/or needed Transportation needs Transportation needs Financial status Financial status Occupational history and interests Occupational history and interests

50 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 50 Agir The French experience The French experience Explore multiple aspects of social, cognitive, medical life. Explore multiple aspects of social, cognitive, medical life. 17 items, 3 possibilities. 17 items, 3 possibilities. 4 B or C required. 4 B or C required.

51 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 51 Indications for a home visit visit Living alone, especially if recently bereaved or separated Living alone, especially if recently bereaved or separated Mental impairment Mental impairment Major mobility problems Major mobility problems Several risk factors for dependency Several risk factors for dependency History of falling or accidents History of falling or accidents Imminent institutionalization Imminent institutionalization Recent hospital discharge, especially if recovery was incomplete Recent hospital discharge, especially if recovery was incomplete

52 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 52 Get Help! Involve social worker and other team members early Involve social worker and other team members early When you are overwhelmed When you are overwhelmed Consider home nursing visits Consider home nursing visits Consider referral to team geriatric program Consider referral to team geriatric program Consider other community referrals (case management programs, etc.) Consider other community referrals (case management programs, etc.)

53 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 53 Geriatric Assessment: The Evidence

54 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 54 Why use assessment instrument? Research Research Clinical practice guide Clinical practice guide Screening (identify unrecognized disease) Screening (identify unrecognized disease) Case finding Case finding Monitor patients throughout course of disorder Monitor patients throughout course of disorder Follow response to treatment Follow response to treatment

55 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 55 Does Geriatric Assessment Improve Outcomes? Results mixed in RCTs Results mixed in RCTs Most robust outcomes seen in studies with a intervention component and follow up Most robust outcomes seen in studies with a intervention component and follow up Increased case finding with GA screens Increased case finding with GA screens Less institutionalization noted in a meta- analysis of GA Less institutionalization noted in a meta- analysis of GA Less disability noted in study of home GA Less disability noted in study of home GA

56 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 56 Summary Aging is a big issue! Focus on function Consider caregivers and abuse Review medications Screen for geriatric syndromes: falls, incontinence, dementia, depression, hearing, vision, pain… Abbreviate and target PE and assessment tools when possible Get help, use a team when possible!

57 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 57


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